Prior authorization reform strategies allows payers to limit unnecessary spending on high-cost prescription drugs, but leading provider experts suggest that payers could do more to boost the efficiency of prior authorization procedures for clinically valid prescription requests.

Value-based payment allows payers to increase efficiency; however, transition to a value based payment model is a slow process involving some risk. To make a successful transition, payers can assess value-based payment models to gain perspective of the challenges and drivers of success.

New study finds over 40 states pursuing value-based payment programs, with 15 multi-payer initiatives across those states. The study reveals a range of approaches and significant variation in the scope, leadership commitment, and resources devoted to the transition from fee-for-service to value-based reimbursement.

Change Healthcare (CH) announced payer insights revealed in The Engagement Gap: Healthcare Consumer Engagement in 2017, a new national study of 89 payers, 251 providers, and 771 consumers. CH asked payers about the factors influencing their consumer-centric initiatives, and how these strategies are altering their organizations. Health plans surveyed were generally aligned in pointing to value-based care as the primary factor driving their focus on consumer-centricity, with 74% reporting it as the leading factor.

Findings from the 11th Annual ReviveHealth Trust Index™ reveal trust in healthcare is dismal across the board, and trust in health plans hit new low. The survey represents the first 360-degree view of trust in healthcare – digging into consumer, physician, health plan, and health system executives’ views of each other – showing the industry as a whole has a long way to go. Factors driving widespread distrust in health plans by provider organizations include the hassle of doing business with payers and a lack of progress toward new models of payment and care. Consumers feel slighted by health plans as well, compared to the higher trust ratings in physicians and hospitals.

The CDC released a report Integrating & Expanding Prescription Drug Monitoring Program Data: Lessons from Nine States detailing a promising strategy for addressing the prescription opioid overdose epidemic. The study focused on improving the use of prescription drug monitoring programs (PDMPs)...

Many health plans are facing uncertainties: the changing health insurance landscape, the speed at which value–based care is approaching, and growing demands from customers, to name a few. But one investment may help executives meet each of these challenges—an investment in analytics. Health plans are data rich, yet those data are not always leveraged to understand what happened and why, or predict what is likely to happen. Health plans that don't take advantage of their data may risk being disrupted and left behind. Analytics can be a key payer competitive differentiator setting your organization ahead of the pack.

Massachusetts bill (H 1070/S 1093) adds to the definition of “medically necessary services” and challenges the notion of who decides medical necessity. Medical necessity criteria sits at the center of case and claim determinations. Laws, policies, and procedures evolve through time and the various administrations both locally and nationally.

The promises of value-based payment models came to life within the last 12+ months with results of real world tests. They quickly move to the implementation of useful models and processes. With ramped-up implementations overcoming value-based care barriers step out as real things.

"BHM provides consultation and direct clinical oversight to East Carolina Behavioral Health as a delegated authority for clinical peer review and physician services. We have been extremely satisfied, and value the organization’s depth and breadth of knowledge. BHM continues to exceed our expectations."

Cindy Ehlers,
V P Clinical Operations, Trillium (formerly ECBH)

"6 of the top 10 largest health plans* entrust BHM for behavioral health peer reviews.